Pioneer Gets Ready to Take Diabetes Education to the Nation

Pittsburgh — Diagnosed in June, Darla Nash joined the many millions of Americans who face the daily grind, the persistent challenges and the often pesky puzzles of diabetes.

Some try ignoring the disease until it pounces with complications. Others deal with it in passing until problems begin emerging. Only a minority, albeit a growing one, responds the way Nash did after her diagnosis. She reacted as one would when a fire trips the alarm, with initial fear giving way to life-saving action.

“I was terrified,” said the 61-year-old White Oak, Pa., woman. “It scared me and woke me up. I really had no choice. I settled within myself that this is what I have to do. I don’t want my diabetes to be out of control.”

And that’s where Nash’s story crosses paths with Linda M. Siminerio, director of the University of Pittsburgh Diabetes Institute.

Soon after her diagnosis, Nash signed up for diabetes education classes, covered by insurance, at University of Pittsburgh Medical Center McKeesport’s Lions Diabetes Center. It is one of 47 diabetes self-management education programs in the region, second in size nationally to North Carolina’s statewide network.

Self-management classes are held in hospitals and health-care facilities region-wide. But in recent years, Siminerio, a nurse who holds a doctoral degree in health care delivery, has worked to expand the network, including having diabetes educators in primary-care physician offices. There, patients who are newly diagnosed or have had challenges with controlling their diabetes can be scheduled for visits. There they can learn proper use of medications, optimal diet, the importance of exercise and how to test and regulate blood sugar.

It equips people with the tools and confidence necessary to respond aptly to the alarm.

In her team’s published research, patients receiving diabetes education in doctor’s office settings reduced blood-sugar levels by 1.2 percent, as measured by the HgA1C blood test. That means levels fell closer to the normal range of 4 to 6 percent.

“Patients felt they had fewer problems and that was linked to the number of visits with diabetes educators,” Siminerio said.

In January, Siminerio was appointed chairman-elect of the National Diabetes Education Program, or NDEP, jointly operated through the National Institutes of Health and the U.S. Centers for Disease Control and Prevention. Created 16 years ago, the program is working to reduce the diabetes epidemic.

“She is a pioneer in the field of diabetes education, a nationally recognized advocate for diabetes education and care, and well recognized in the diabetes community,” said Joanne Gallivan, the NIH director of NDEP.

Strategies developed by and research led by Siminerio have translated successfully into programs to help all people with diabetes, but specifically those in underserved populations. “All of that experience has led to nominating Linda to be chairwoman of the NDEP.”

In the position, Siminerio will work yearlong with NDEP leaders with one goal of taking local programs nationwide once she becomes chairwoman next January.

“We have to use the whole health-care structure with medical practices all over the region,” Siminerio said, concerning community-based programs for diabetes education. “That’s why we are working with primary-care physicians and working proactively rather than waiting for references to the program. We have to get to the patients and not wait for them to come to us.

“That’s the optimal goal.”

Strategies that already are going national include a team approach to improve care, provide better access to diabetes education, use telemedical services for people in underserved areas and convince physicians to buy into the self-management education strategy emphasizing early instruction and encouragement to help stall out the diabetes epidemic.

Siminerio long has advocated team care involving health professionals, a dietitian, the local pharmacist, family members, friends and others. Each team member plays a treatment, support or advisory role to help the person keep blood sugar, weight, blood pressure and cholesterol within recommended guidelines.

Pitt’s Diabetes Institute also has a pilot project to make a UPMC endocrinologist available through video-conferencing to treat patients, with assistance from a diabetes educator. The telemedicine program for patients in Bedford and Venango counties has resulted in reduced A1C in the small number of patients treated to date.

A Glucose to Goal program opts to have physicians prescribe diabetes education shortly after diagnosis and for those having challenges in improving their diabetes control. The main goal is to make diabetes education as routine a step in treatment as rehabilitation therapy is for people who undergo physical therapy after hip surgery.

Now Siminerio, who’s held leadership positions with the American Diabetes Association and the World Health Organization, is ready to turn pilot projects into standard tools of diabetes care.

The ADA estimates that nearly 27 million Americans have diabetes with the majority involving adults with type 2 diabetes. Type 2 often afflicts people who are overweight, lack exercise or have a poor diet, which can make the body insensitive to its own insulin. Type 1 diabetes involves an autoimmune attack on the insulin-producing beta cells in the pancreas. In both cases, insufficient insulin - the hormone that converts blood glucose into cell energy - leads to a buildup of glucose in the blood to levels dangerous to health and even deadly.

Diabetes care and its economic impacts cost the nation $245 billion in 2012, the American Diabetes Association reports. Two of three people with diabetes eventually will die from heart disease, it says.

Good control is defined as those who meet the ABCs of diabetes care, as defined by the ADA:

“A” involves the HgA1C, or A1C blood test, which provides a three-month average percentage of glucose levels in the blood. The ADA recommends blood glucose below 7 percent, with the normal range generally considered to be 4 to 6 percent.

“B” represents normal blood pressure of 130/80 or lower.

“C” involves keeping LDL cholesterol below 100 and HDL 40 or higher.

Normal ABC levels help prevent complications that can include heart disease, stroke, kidney disease leading to renal failure, eye problems leading to blindness, and circulatory disorders that can lead to lower limb amputations, along with a higher risk for other diseases and conditions.

And that is where diabetes education enters the scene.

The educator’s big challenge is convincing people to forfeit their American lifestyle and diet, in favor of healthful food, more exercise and daily efforts to maintain normal or near-normal blood-sugar levels.

Janice Koshinsky, diabetes program manager at the Lions Diabetes Center, and dietitian Carla DeJesus must be equal parts educators, psychologists and motivators.

“We have patients who say their doctor wants them to lose 50 to 70 pounds,” she said. “We ask them, ‘What do you think is reasonable?’ They set their goals, and we help them meet them,” Koshinsky said. “We are looking for progress, not perfection.”

Along the way, the educators address various obstacles, including depression. One man, DeJesus said, rarely left his house. Once he finally arrived for education, she convinced him to consider counting carbohydrates to better control blood sugar. That led to her advice to reduce consumption of his favorite sugar beverage from one gallon to a half gallon a day. More recently he agreed to use the diet version.

“He is really depressed and finally opened up to me,” she said. “He said, ‘I can’t believe how much I’m saying to you.’ We were able to get to the root of what was causing him not to care for his diabetes.”

People know they should eat healthy food and exercise, but Koshinsky asked rhetorically, “How many people do what’s best?”

Studies show that patients who undergo diabetes education are more likely to reach ABC targets.

“The biggest challenge is people who never get here,” Koshinsky said. “They don’t understand the benefits and don’t choose to come. Even if they have an attitude when they get here, if you spend enough time with the patient, an educator can move them along the continuum of readiness. Maybe they will go home and make an effort.”

Another problem is convincing physicians to send patients for diabetes education upon diagnosis rather than waiting for complications to occur. In those cases, DeJesus said, the head-shaking reality is “why didn’t the doc tell the patient to come sooner? It’s sad.”

But the focus is potential not frustration. Feedback is important. Knowledge is power. Diabetes educators can help patients reach ABC targets better than physicians burdened by limited appointment time.

“Once they understand the number and have good targets, they are engaged,” Koshinsky said.

Once scared, now empowered, Nash represents the success of diabetes education.

She walks two miles a day, has eliminated sugar from her diet and counts carbohydrates. She regularly tests her blood sugar. So far she’s lost 30 pounds and her A1C dropped from 8.7 percent to about 7 percent, near the upper level of ADA’s benchmark levels for control. She said she is working to lower it.

With hypertension medications, her blood pressure is 110/60, well within ADA guidelines. Her total cholesterol, with help from statin drugs, has dipped below 200.

“I have lost 30 pounds and walk five days a week,” said Nash, who takes the oral medication metformin to help reduce blood sugar. “I’ve done everything they’ve told me to do. I can’t say it has been easy, especially at Christmastime, but I have had success and everyone is pleased.

“I’m not perfect but I thank God for the classes I took,” she said. “Without them, I wouldn’t know what to do.”

That sums up the team concept. Educators credit Nash, while she credits the Koshinsky-DeJesus team.

“I can’t say enough how wonderful they were,” she said. “No one in my family had diabetes. I knew nothing about it. All I knew was to stay away from sugar.